Both environmental improvement and collective agency over local decisions are recognised strategies for promoting health and health equity. However, both strategies have been critiqued for their association with policies that emphasise local resources and decision-making while the state disinvests in social and environmental determinants of health. This paper explores the role of place-based community empowerment initiatives in building collective control and improving health. We examined the perspectives of participating communities using qualitative data from interviews and observational fieldwork embedded within an evaluation of a national community empowerment initiative: Big Local (funded by The National Lottery Community Fund and overseen by Local Trust). We selected five examples of community action to improve and maintain built environments. We found that while academics (including the authors) are interested in mechanisms to health impacts, participants focused on something more general: delivering benefits to their communities and maintaining services threatened by state disinvestment. Participants sometimes used ‘health’ as a pragmatic justification for action. We posit that systemic pathways to health impact are plausible even when communities themselves do not forefront health goals. For example, ‘quick wins’ and ‘quick losses’ resulting from early community action have potential to galvanise or undermine collective agency, and so affect communities’ capability to deliver future improvements to social and environmental determinants of health. However, structural limitations and unequal access to resources limit the potential of communities to make health-promoting change, as some participants acknowledged. Collective agency may improve socio-environmental determinants of health but systemic barriers to empowerment and equity persist.